CTO of ostial LAD (retrograde technique)

  • Live center: Institut Cardiovasculaire Paris Sud Massy - France
  • Operators: Osamu KATOH, T. LEFEVRE, Mohamed ABDELLAOUI
  • Patient: CC, 72 y.o.
  • Type of procedure: Coronary
  • Level: Complex
  • Access type: Retrograde, Femoral
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Risk factors

Hypertension
Hypercholesterolemia
Ex- smoker

Euroscore: 3 (predicted mortality from CABG: 2.1)

Past/Clinical history

Silent myocardial ischemia

Exertional dyspnoea

Positive stress test

Lesions

Chronic total occlusion of ostial LAD with collateral circulation from the RCA
  • Length: 40
  • Retinal vessel diameter: 3.5
  • Lesion subset: Chronic total occlusion of ostial LAD with collateral circulation from the RCA
  • Therapeutic techniques: Retrograde approach


Angiography



Strategy

Retrograde approach via the septal collaterals ?

Key points

Should we attempt this lesion ?

What is the optimal approach to this kind of lesion ?

How to perform the retrograde approach ?

BOSTON SCIENTIFIC
Maverick 2 ™ Monorail Balloon 2  x 20  x 1
Maverick Balloon 2.5  x 23  x 1
Maverick Balloon 3  x 20  x 1
Promus Stent 2.5  x 28  x 1
Promus Stent 2.5  x 23  x 1
CORDIS, a Johnson & Johnson Company
Dura Star Balloon 3  x 15  x 1
Cypher Select Stent 2.5  x 28  x 1
GOODMAN
Lacrosse Balloon Balloon 1.3  x 10  x 1
GUIDANT
BMW x 1
JOMED
ASAHI NEO´S Guide wire x 3
X-treme wire Guide wire x 1
MEDTRONIC
JR 4 7F Catheter x 1
EBU 4 8F Catheter x 1
TERUMO
Femoral 7F Introducer Sheath x 1
Femoral 8F Introducer Sheath x 1
Finecross 1.8F Catheter x 1

Take home message

Safety and effectiveness of the retrograde approach in selected cases of chronic occlusion

"Mental power"

Final result

  • Final result : MSCT demonstrated that the occlusion was of the mid LAD after the first diagonal branch

    MSCT demonstrated that the occlusion was of the mid LAD after the first diagonal branch

  • Final result : EBU 4.0 8F guiding catheter in LMS. BMW wire in first diagonal. IVUS examination of proximal LAD to locate entry into true lumen.

    EBU 4.0 8F guiding catheter in LMS. BMW wire in first diagonal. IVUS examination of proximal LAD to locate entry into true lumen.

  • Final result : 24/05/2007: RCA cannulation with JR4 7F guiding catheter in preparation for retrograde approach caused ostial dissection - treated by d

    24/05/2007: RCA cannulation with JR4 7F guiding catheter in preparation for retrograde approach caused ostial dissection - treated by deployment of a single 4.5 x 24mm PROMUS stent

  • Final result : 1st and 2nd diagonal branches wired via antegrade approach. Unable to advance wire into true lumen of LAD. Via retrograde approach, bal

    1st and 2nd diagonal branches wired via antegrade approach. Unable to advance wire into true lumen of LAD. Via retrograde approach, balloon dilatation of septal branch and then wire advanced back through LAD occlusion and into guiding catheter.

  • Final result : Distal LAD lumen now visualised and wire advanced antegradely

    Distal LAD lumen now visualised and wire advanced antegradely

  • Final result : Predilatation of proximal and mid LAD and bifurcation (kissing inflation 2.5 and 2.0mm Maverick). Stenting of Mid LAD: PROMUS 2.5 X 28m

    Predilatation of proximal and mid LAD and bifurcation (kissing inflation 2.5 and 2.0mm Maverick). Stenting of Mid LAD: PROMUS 2.5 X 28mm, then 2.5 x 23mm PROMUS distally.

  • Final result : After final kissing inflation: LAD 3mm, Diagonal 2.5mm Maverick; 
Final good angiographic result in LAD and diagonal. Distal LCX treat

    After final kissing inflation: LAD 3mm, Diagonal 2.5mm Maverick; Final good angiographic result in LAD and diagonal. Distal LCX treated with PROMUS 2.5 x 15mm afterwards.


Follow-up

  • Follow up : Patient currently asymptomatic.

Normal dobutamine stress echocardiogram.

Angiography at 9 months satisfactory showing no restenosis.

    Patient currently asymptomatic.Normal dobutamine stress echocardiogram.Angiography at 9 months satisfactory showing no restenosis.

  • Follow up : Second view of good result of ostial LAD stenting at 9 months.

    Second view of good result of ostial LAD stenting at 9 months.


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